Faculty Bibliography

ABSTRACT/UNASSIGNED:This is the Western Trauma Association's recommended algorithm for the management of a traumatic lung injury. The current algorithm and recommendations are based on available published randomized trials, observational studies, systematic reviews, and the expert opinion of the Western Trauma Association members. The algorithm and accompanying text represent a safe and reasonable approach to this common problem. We recognize that there may be variability in decision-making, local resources, institutional consensus, and patient-specific factors that may require deviations from the presented algorithm. This annotated algorithm is meant to serve as a basis from which protocols at individual institutions can be developed or serve as a quick bedside reference for clinicians. LEVEL OF EVIDENCE/METHODS:Consensus algorithm from the Western Trauma Association, Level V. (J Trauma Acute Care Surg. 2026;101: 187-198. Copyright c 2026 Wolters Kluwer Health, LLC. All rights reserved.).

Study DesignRetrospective Cohort Study.ObjectivesTo determine the incidence of symptomatic retroperitoneal fluid collections (RFCs) following anterior lumbar interbody fusion (ALIF), characterize clinical presentation, and identify independent predictors and associated complications.MethodsBetween 2014 and 2023, adult patients who underwent 1- to 4-level primary or revision ALIF at a single academic university-affiliated hospital were retrospectively reviewed for postoperative RFCs. Asymptomatic RFCs, <1 year follow-up, and surgical indications for trauma, malignancy, or infection were excluded. Symptomatic RFCs, including lymphoceles, hematomas/seromas, abscesses, and urinomas, were identified on postoperative MRI with final classification based on fluid aspiration when available. Multivariable logistic regression was performed to identify independent predictors of RFCs and associations with postoperative complications.ResultsAmong 553 included patients, 44 (7.97%) developed symptomatic postoperative RFCs, most commonly seromas, presenting with abdominal pain and distension. Multi-level surgeries (aOR: 4.472), estimated blood loss ≥725 mL (aOR: 4.213), intraoperative transfusion (aOR: 3.347), L4-5 fusion (aOR: 3.186), higher ASA class (aOR: 2.291), and venous injury (aOR: 2.051) (all P < 0.05) were independent predictors of RFCs. L3-4 fusion provided a protective effect (aOR: 0.163). RFCs were associated with increased risk of subsequent deep vein thrombosis (DVT; aOR: 4.087, P = 0.007) and incision and drainage (aOR: 9.593, P = 0.005).ConclusionsSymptomatic RFCs occurred postoperatively in 7.97% of ALIF cases. Multi-level fusion, blood loss ≥725 mL, intraoperative transfusion, L4-5 fusion, higher ASA class, and venous injury were independently associated with RFC development. Notably, RFCs increased risk of postoperative DVT by 4 times, underscoring the benefit of early recognition in high-risk patients.

Dissection morphology is important when considering landing zones for thoracic endovascular aortic repair. Landing proximally in a healthy aorta, free of dissection and intramural hematoma, is generally recommended. For the most common location of the proximal entry tear near the left subclavian artery, this generally requires landing in zone 2. However, zone 2 landing is associated with higher rates of stroke and need for left subclavian revascularization. Distal landing zone 5 is associated with much higher rates of spinal cord ischemia, without significant benefit over zone 4 or bare metal stent extension so should be avoided, especially for treatment of uncomplicated dissections.

Patient and stakeholder engagement is increasingly emphasized in clinical research, yet practical guidance on how to operationalize engagement in high-acuity, multicenter surgical trials remains limited. We describe the design and early implementation of a structured engagement strategy within the IMPROVE-AD (Improving Outcomes in Vascular Disease-Aortic Dissection) trial. IMPROVE-AD is a pragmatic, multicenter randomized trial comparing optimal medical therapy alone with optimal medical therapy plus thoracic endovascular aortic repair for uncomplicated type B aortic dissection. A formal patient engagement committee, supported by a stakeholder engagement core, was established to integrate patient perspectives into trial design and conduct. Engagement activities included inputs on trial design, recruitment strategies, participant-facing materials, and communication approaches. Observations were derived from the early implementation of these activities. Stakeholder engagement informed several aspects of trial development and implementation. Early engagement contributed to the refinement of trial design elements, including the prioritization of clinical endpoints over surrogate measures. During trial implementation, patient engagement committee input supported the revision of informed consent language, development of public-facing materials, and refinement of recruitment messaging, with an emphasis on clarity, transparency, and clinical equipoise. Access to aggregated screening and enrollment data enabled the identification of potential barriers to recruitment and underrepresentation. These observations are descriptive. A formal evaluation of the impact of engagement on enrollment, retention, or other trial outcomes has not yet been conducted. Structured stakeholder engagement can be incorporated into the design and conduct of a high-acuity, multicenter randomized trial and may inform communication, recruitment, and implementation strategies. Although the full model described here is resource intensive, selected elements may be adaptable across diverse research settings. Further work is needed to evaluate the impact of engagement and to identify scalable approaches.

Uncomplicated Type B aortic dissection (uTBAD) treatment is changing, and the evidence driving this change is scarce. The decision to offer upfront thoracic endovascular aortic repair (TEVAR) or medical therapy varies significantly among providers, driven more by individual preference than scientific evidence. The IMPROVE-AD trial is a randomized, multidisciplinary, prospective, controlled, superiority trial designed to compare treatment efficacy; functional outcomes; quality of life; and costs in patients with uTBAD undergoing upfront TEVAR or medical therapy with selective TEVAR for deterioration during follow-up. In all, 60 clinical sites in the United States and Canada will enroll 1,100 patients with uTBAD, who are candidates for both treatment options and randomized in a 1:1 ratio. The primary efficacy endpoint of the trial is all-cause mortality and major aortic complications at 4 years. The IMPROVE-AD trial is the only ongoing North America-based large pragmatic trial comparing upfront TEVAR to medical therapy with selective TEVAR in patients with uTBAD. This landmark comparative effectiveness trial aims to provide Level I data to clarify the appropriate role for both treatment strategies and inform clinical practice.

An initial presentation of severe chest or back pain with uncontrolled hypertension in the absence of cardiac etiology is synonymous with aortic dissection. For aortic dissections that do not involve the ascending aorta, malperfusion, or rupture, initial treatment with blood pressure management is favored to reduce short- and mid-term morbidity and mortality. Although medical management with surveillance remains broadly recommended for uncomplicated Type B aortic dissection, stent graft placement has emerged as a potential "disease-modifying" intervention. However, the following questions remain: What disease and patient features represent a cohort with the highest risk of downstream complications? And, can early thoracic endovascular aortic stent placement mitigate these risks? We reviewed the impact of recurrent pain and uncontrolled hypertension for uncomplicated Type B aortic dissection. Overall, available data are from observational studies or case series, with inconsistent terminology and conflicting results. We suggest that persistent pain or hypertension should not be used as an automatic trigger for surgery, but rather a prompt to aggressively evaluate for conversion of uncomplicated disease to complicated disease with malperfusion or impending rupture. Indication for surgical treatment in this setting should clearly be documented as conversion to complicated dissection.

Clinical equipoise-genuine uncertainty within the expert community regarding the relative merits of competing treatments-forms the ethical and scientific foundation of randomized controlled trials. The growing adoption of thoracic endovascular aortic repair (TEVAR) for uncomplicated type B aortic dissection (uTBAD) has increasingly challenged the principle of clinical equipoise in the treatment algorithm of uTBAD. Optimal medical therapy remains the accepted standard in the treatment of uTBAD. However, the expanding role of TEVAR has led some clinicians and institutions to view early intervention as beneficial, despite the lack of definitive comparative data. Randomized controlled trials, such as INSTEAD, INSTEAD-XL, and ADSORB, have demonstrated that TEVAR promotes false-lumen thrombosis and remodeling, but have not shown a clear survival benefit over optimal medical therapy. Retrospective studies frequently suggest favorable aortic remodeling and improved survival with TEVAR, yet these associative findings cannot establish causality and fall short of the evidentiary strength required to resolve treatment uncertainty. Contemporary guidelines reflect this ambiguity by endorsing aggressive medical therapy with selective TEVAR for anatomically high-risk patients. In the absence of definitive data, practice patterns have been shaped by institutional culture. Persistent uncertainties underscore the need for a definitive randomized trial. These unresolved questions underscore the persistence of clinical equipoise and the ethical necessity for a definitive randomized trial. Equipoise is challenged by institutional culture, specialty bias, referral patterns, patient expectations, and device marketing. Clinical equipoise in uTBAD will be resolved by adequately powered trials demonstrating improvement in patient-centered outcomes. Surrogate measures of aortic remodeling are insufficient.